A Quality Improvement Approach to Reduce 30-day Readmissions and Mortality in Patients with Acute Decompensated Heart Failure

ObjectivesHeart failure [HF] hospital readmissions are a continued challenge in the care of HF patients, which contribute substantially to the high costs of the disease and high mortality rate in lower to middle income country. We implemented a quality improvement project to improve patient outcomes and resource utilization.MethodsThis study was a prospective cohort design with a historical comparison group. It was conducted to assess the difference in 30-day readmissions and mortality and to assess compliance rate with HF guideline between the historical pre-intervention audit 1 cohort and prospective post-intervention audit 2 cohorts. Audit 1 cohort were recruited from January to February 2019, whereas, audit 2 cohort which received the bundled intervention program were recruited from July to December 2019. Clinical outcomes were compared between cohorts using 30-day readmissions and mortality.ResultsA total of 50 and 164 patients were included in audit 1 and audit 2 cohort, respectively. Patients in the audit 2 cohort were younger [63.0 ± 14.5 in audit 1 vs 56.5 ± 12.7 in audit 2, p = 0.003] and majority were male [50.0% in audit 1 vs 72.0% in audit2, p = 0.004]. Thirty-day readmissions were significantly different [36.0% audit 1 vs. 22.0% audit 2, p = 0.045], but the mortality rates were similar [4.0%% audit 1 vs. 5.5% audit 2, p = 0.677] between two cohorts.ConclusionA significant decrease in 30-day readmissions was observed in the post-intervention audit 2 cohort in our setting. Further study in larger population and prolong study follow-up is warranted.     

心力衰竭管理模式探讨

目的:评价不同管理模式对慢性收缩性心力衰竭(心衰)患者神经内分泌、心功能、心脏事件、生活质量和医疗费用的影响。方法:120例慢性心功能不全患者,在常规治疗心衰的前提下,随机分为心衰管理组和心衰非管理组各60例,治疗后两年其对神经内分泌、心功能、心脏事件、生活质量和医疗费用的影响。结果:心衰管理组治疗后心功能、生活质量、神经内分泌较心衰非管理组治疗后改善(P<0.05),心衰恶化再入院减少(P<0.05),心脏事件较心衰非管理组明显减少(P<0.05),年心衰治疗费用较后者减少(P<0.05),差异均有统计学意义。结论:通过心衰管理能改善心功能及生活质量,减少心衰医疗费用、心脏事件的发生。     

Incidence and mortality of heart failure: A community-based study

Background

Data on the incidence and mortality of heart failure (HF) in community-based populations of developed countries are limited. We estimated the trends of the incidence and, the mortality of HF.

Methods

Prospective population-based study in a white, low-middle class Mediterranean community of 267,231 inhabitants in Spain. Participants were all the patients (= > 14 years), newly diagnosed with HF (4793), according to the Framingham criteria, from January 1, 2000 through December 31, 2007. Main outcome were incidence and mortality following an HF diagnosis.

Results

Incidence of HF increased among both men and women, and among persons with systolic and non-systolic HF. Incidence of HF increased from 296 per 100,000 person-years in 2000 to 390 per 100,000 person-years in 2007 (RR 1.32, CI 95% 1.27-13.7, P < .01). Although, risk-adjusted mortality declined from 2000 to 2007, the prognosis for patients with newly diagnosed HF remains poor. In 2007, risk-adjusted 30-day, 1-year, and 4-years mortality was 12.1%, 28.8%, and 61.4%, respectively. Incidence and mortality of systolic HF were higher than those of non-systolic HF (P < 0.05).

Conclusions

During the last 8 years, in a white, middle class population of the south of Europe, the increased incidence and the decreased mortality of heart failure have resulted in an increased prevalence of heart failure. Incidence and mortality of systolic heart failure were higher than those of non-systolic heart failure.     

Use of a novel ultrafiltration device as a treatment strategy for diuretic resistant, refractory heart failure: initial clinical experience in a single center

BackgroundThe System 100 UF device allows ultrafiltration (UF) via peripheral access and is approved for use in heart failure (HF), although clinical trials defining optimal target population and clinical utility are lacking. We report our initial experience with clinical use of this system in very advanced, diuretic resistant HF patients.Methods and ResultsEleven HF patients (mean age 70 years) underwent 1 to 5 UF treatments each (total 32 UF). The goal was to remove 4 liters of fluid per 8-hour UF. Baseline creatinine averaged 2.2 mg/dL (range .9–3.2) while estimated glomerular filtration rates (GFRs) averaged 38 mL/min (range 20–87). Nine patients (82%) had moderate (GFR 30–59; n = 3) or severe (GFR <30; n = 6) renal dysfunction. Nine patients (82%) had documented right ventricular dysfunction, 6 with severe tricuspid regurgitation. Average daily intravenous furosemide dose prior to UF was 258 mg (range 80–480). Patients had received nesiritide (n = 4), dopamine (n = 4), and zaroxylyn (n = 7) prior to UF. Of the 32 UF treatments, 13 (41%) removed >3500 mL, 11 (34%) removed 2500–3500 mL, and 8 (25%) removed <2500 mL. Only one UF treatment (3%) was aborted due to hypotension. There were no significant complications related to UF. Five patients (45%) experienced an increase in creatinine of >.3 mg/dl. Five patients required dialysis for persistant diuretic resistant volume overload or uremic symptoms. Six-month mortality was 55%.ConclusionsPeripheral UF safely but variably removed fluid. In this very high-risk, advanced HF population, 45% of patients developed worsening renal function during UF therapy. Controlled studies are needed to determine the impact of UF on renal function and outcomes in high-risk populations such as this.     

Influence of progressive renal dysfunction in chronic heart failure

Chronic heart failure (CHF) is often associated with impaired renal function due to hypoperfusion. Such patients are very sensitive to changes in renal perfusion pressure, and may develop acute tubular necrosis if the pressure falls too far. The situation is complicated by the use of diuretics, ACE inhibitors and spironolactone, all of which may affect renal function and potassium balance. Chronic renal failure (CRF) may also be associated with fluid overload. Anaemia and hypertension in CRF contribute to the development of left ventricular hypertrophy (LVH), which carries a poor prognosis, so correction of these factors is important.     

连续性肾脏替代疗法抢救急危重症43例疗效分析

目的 :总结连续性肾脏替代疗法 (CRRT)对各类重症疾病的疗效 ,旨在总结经验 ,提高疗效。方法 :CRRT治疗的 4 3例重症患者按病因分类 ,并分析各类疾病CRRT前后神志、肝、肾功能、电解质及生命体征的变化。结果 :8例肾移植后急性肾功能衰竭者经CRRT治疗后 8～ 16hSCr、BUN逐渐下降。 7例肝性脑病、肝肾综合征及 4例多脏器衰竭者经CRRT治疗后 ,2例肝昏迷者神志恢复 ,4例肾功改善 ,治疗中生命体征稳定。 8例因脑卒中高钠血症者在行CRRT治疗 8～12h后血钠下降。结论 :①肾移植后急性肾功能衰竭患者经CRRT治疗后肾功能恢复时间明显缩短。②对肝性脑病、肝肾综合征患者 ,CRRT可改善神志及肾功能 ,延长存活时间 ,为行肝移植赢得时间。③CRRT能降低脑卒中高钠血症 ,疗效好     

In‐hospital worsening heart failure

Acute worsening heart failure (WHF) is seen in a sizable portion of patients hospitalized for heart failure, and is increasingly being recognized as an entity that is associated with an adverse in‐hospital course. WHF is generally defined as worsening heart failure symptoms and signs requiring an intensification of therapy, and is reported to be seen in anywhere from 5% to 42% of heart failure admissions. It is difficult to ascertain the exact epidemiology of WHF due to varying definitions used in the literature. Studies indicate that WHF cannot be precisely predicted on the basis of baseline variables assessed at the time of admission. Recent data suggest that some experimental therapies may reduce the risk of development of WHF among hospitalized heart failure patients, and this is associated with a reduction in risk of subsequent post‐discharge cardiovascular mortality. In this respect, WHF holds promise as a endpoint for acute heart failure clinical trials to better elucidate the benefit of targeted novel therapies. Better understanding of the pathophysiology and a consensus on the definition of WHF will further improve our epidemiological and clinical understanding of this entity.     

European Society of Cardiology Heart Failure Association Standards for delivering heart failure care

The management of heart failure (HF) is complex. As a consequence, most cardiology society guidelines now state that HF care should be delivered in a multiprofessional manner. The evidence base for this approach now means that the establishment of HF management programmes is a priority. This document aims to summarize the key elements which should be involved in, as well as some more desirable features which can improve the delivery of care in a HF management programme, while bearing in mind that the specifics of the service may vary from site to site. We envisage a situation whereby all patients have access to the best possible care, including improved access to palliative care services, informed by and responsive to advances in diagnosis management and treatment. The goal should be to provide a 'seamless' system of care across primary and hospital care so that the management of every patient is optimal, no matter where they begin or continue their health-care journey.     

硫酸特布他林治疗重症肺心病的研究

目的为探讨硫酸由他林（ＴＢＴ）在重症肺心病中的治疗价值。方法对６２例伴有呼衰和心衰的肺心病患者进行临床和动脉血气监测。并随机对其中３０例在常规治疗的基础上加服ＴＢＴ。结果ＴＢＴ既可显著提高综合治疗的疗效（Ｐ〈０．０５）,又可促进心肺功能的改善以显著提高ＰａＯ２（Ｐ〈０．０５）、降低ＰａＣＯ２;未见明显不良反应。结论ＴＢＴ是治疗重症肺心病的一种有效药物。     

肺结核并发呼吸衰竭50例临床分析

目的 :探讨肺结核并发呼吸衰竭的临床特点。方法 :对 5 0例肺结核并发呼吸衰竭进行回顾性分析。结果 :5 0例均为重症肺结核 ,复治肺结核占 98% ,以肺部感染为诱因者占 4 6 % ,其他诱因为咯血 (2 0 % )、病灶进展 (18% )、气胸 (16 % )。Ⅱ型呼衰占 90 %。均有一种或一种以上并发症 ,多器官功能衰竭 (MOF) 4 8% ,经常规治疗 6 2 %缓解 ,19例 (38% )死亡 ,第一次呼衰至死亡时间平均为 2 .4年 ,并发MOF者病死率高达 75 %。结论 :重症肺结核易导致呼衰 ,肺部感染为诱因多见 ,易并发MOF ,病死率高 ,一旦发生呼衰生存期短     

Current concept in the diagnosis,treatment and rehabilitation of patients with congestive heart failure

Heart failure(HF) is a major public health problem with a prevalence of 1%-2% in developed countries. The underlying pathophysiology of HF is complex and as a clinical syndrome is characterized by various symptoms and signs. HF is classified according to left ventricular ejection fraction(LVEF) and falls into three groups: LVEF ≥ 50%-HF with preserved ejection fraction(HFpEF), LVEF 40%-HF with reduced ejection fraction(HFrEF), LVEF 40%-49%-HF with mid-range ejection fraction. Diagnosing HF is primarily a clinical approach and it is based on anamnesis, physical examination, echocardiogram, radiological findings of the heart and lungs and laboratory tests, including a specific markers of HF-brain natriuretic peptide or N-terminal pro-B-type natriuretic peptide as well as other diagnostic tests in order to elucidate possible etiologies. Updated diagnostic algorithms for HFpEF have been recommended(H2 FPEF, HFA-PEFF). New therapeutic options improve clinical outcomes as well as functional status in patients with HFrEF(e.g., sodium-glucose cotransporter-2-SGLT2 inhibitors) and such progress in treatment of HFrEF patients resulted in new working definition of the term "HF with recovered left ventricular ejection fraction". In line with rapid development of HF treatment, cardiac rehabilitation becomes an increasingly important part of overall approach to patients with chronic HF for it has been proven that exercise training can relieve symptoms, improve exercise capacity and quality of life as well as reduce disability and hospitalization rates. We gave an overview of latest insights in HF diagnosis and treatment with special emphasize on the important role of cardiac rehabilitation in such patients.     

左心室射血分数保留的心力衰竭研究现状

心室的收缩与舒张功能异常均可能使心脏排血量降低并导致心力衰竭。长期以来我们更多关注的是因心室收缩功能障碍所致的心力衰竭,而对于左室收缩功能正常的心力衰竭的病理生理机制以及诊疗策略却所知很少。在临床实践中因心室舒张功能障碍所导致的心力衰竭约占患者总数的50%左右,其预后与收缩性心力衰竭相似,但猝死的发生更为常见。现结合近年来发表的相关文献对其研究现状进行简要总结。     

缓慢持续型慢加急性肝衰竭与慢性肝衰竭的甄别*

正肝衰竭是多种因素引起的严重肝脏合成和代谢功能紊乱,以黄疸、凝血功能障碍为主要表现的一组临床症候群。临床常见肝衰竭类型包括慢加急性肝衰竭(acute-on-chronic liver failure,ACLF)和慢性肝衰竭。缓慢持续型ACLF与慢性肝衰竭的临床表现类似,部分缓慢持续型ACLF患者可发展为慢性肝衰竭,两者容易发生混淆。现从疾病概念、慢性肝病基础、病理学特征、起病过程、肝功能损伤的主要指标,即总胆红素和凝血功能指标、对人工肝治疗反应和疾病预后转归等方面进行如下甄别。     

Plasma exchange in patients with acute and acute-on-chronic liver failure: A systematic review

BACKGROUND Acute liver failure(ALF)and acute-on-chronic liver(ACLF)carry high short-term mortality rate,and may result from a wide variety of causes.Plasma exchange has been shown in a randomized control trial to improve survival in ALF especially in patients who did not receive a liver transplant.Other cohort studies demonstrated potential improvement in survival in patients with ACLF.AIM To assess utility of plasma exchange in liver failure and its effect on mortality in patients who do not undergo liver transplantation.METHODS Databases MEDLINE via PubMed,and EMBASE were searched and relevant publications up to 30 March,2019 were assessed.Studies were included if they involved human participants diagnosed with liver failure who underwent plasma exchange,with or without another alternative non-bioartificial liver assist device.RESULTS Three hundred twenty four records were reviewed,of which 62 studies were found to be duplicates.Of the 262 records screened,211 studies were excluded.Fifty-one articles were assessed for eligibility,for which 7 were excluded.Twenty-nine studies were included for ALF only,and 9 studies for ACLF only.Six studies included both ALF and ACLF patients.A total of 44 publications were included.Of the included publications,2 were randomized controlled trials,14 cohort studies,12 case series,16 case reports.All of three ALF studies which looked at survival rate or survival days reported improvement in outcome with plasma exchange.In two out of four studies where plasma exchange-based liver support systems were compared to standard medical treatment(SMT)for ACLF,a biochemical improvement was seen.Survival in the non-transplanted patients was improved in all four studies in patients with ACLF comparing plasma exchange vs SMT.Using the aforementioned studies,plasma exchange based therapy in ACLF compared to SMT improved survival in non-transplanted patients at 30 and 90-d with a pooled OR of 0.60(95%CI 0.46-0.77,P<0.01).CONCLUSION The level of evidence for use of high volume plasma exchange in selected ALF cases is high.Plasma exchange in ACLF improves survival at 30-and 90-d in nontransplanted patients.Further well-designed randomized control trials will need to be carried out to ascertain the optimal duration and amount of plasma exchange required and assess if the use of high volume plasma exchange can be extrapolated to patients with ACLF.